Billing, Coding, and Documentation

Question 1

WHat is computerized provider order entry

Answer 1

CPOE

replace paper-based ordering systems
common
improves safety
electronic ordering of meds/ referrals

Question 2

What is clinical decision support system?

Answer 2

prevents errors when provided with CPOE

suggests default values
drug safety (drug-drug)
flags
have to click through a bunch of things so that you can override or change the medication

not perfect!
users often use work arounds to bypass safety features
can lead to alert fatigue - as admissions have a lot of safety alerts

Question 3

what is the principles of domunetation

Answer 3

transcend communication barriers
among providers and facilitates
reimbursement
litigation
public health initiatives

document x3

Question 4

Types of unintended consequences of CPOE

Answer 4

more work for clinicians
unfavorable workflow issues (older generation)
never-ending system demands with updates
problems with paper orders (trying to get them into your system might be difficult)
New types of errors
Unexpected changes

Question 5

written records pros and cons

Answer 5

sometimes faster
human error (bad hand writing)
harder for communication between healthcare facilities

Question 6

electronic record pros and cons

Answer 6

Organized at one spot so you do not have to race to charts
Past visits easy to access
Downtime d/t computer systems going down

Question 7

Templated notes

Answer 7

Click boxes
Enhance legibility
Can do cut and paste of things that you always say (but can lead to errors) make sure to modify to prevent errors

Question 8

What is medicare established by?

Answer 8

CMS

Question 9

Medicare pays hospital for IPPS, what is this?

Answer 9

Inpatient prospective payment system
-relies on diagnostic order with most important differential at top in order to get paid

Question 10

3 Key components of documentation

Answer 10

History
PE
Medical decision making

time is also one, but often not billed (sometimes is though)

Question 11

Elements of history

Answer 11

CC: resent for visit (in progress note)
HPI: conveys info about CC (LOCATES), quantify as brief 1-3 or extended 4+
ROS: 14 recognized systems (problem pertient 1 (2-9) 10+
FH: pertininent is one of three, complete is all 3
SH:

Question 12

what does an H&P need to be?

Answer 12

comprehensive

Question 13

PE

Answer 13

problem focused 1
expanded problem focused 2-7
detailed 2-7 (with at least 2 comments per organ system
comprehensive = 8+

Question 14

What is medical decision making (MDM)?

Answer 14

MDM = straightforward, low, moderate, or high difficulty of services

of diagnosis
the amount and complexity of data
the risk of the patient

important to do accurate so that you do not overbill = fraud

Question 15

MDM # of diagnosis

Answer 15

identifies # of dx
needs to ELABORATE for medical decision making

Question 16

MDM the amount and complexity of data

Answer 16

reviewed with patients
refers to data reviewed

amount/complexity of order

Question 17

What is the risk of the patient

Answer 17

risk
morbidty/mortaltiy

minimal, low, moderate, and high (often IV)

need to specify in notes about labs/diagnoses and how that can expose the patient to risk

Question 18

How to assign MDM complexity

Answer 18

at least 2 out of the 3 highest value categories to select that level (chose the lowest of the two remaining ones, and the lowest is thrown out)

Question 19

subsequent follow ups =

Answer 19

coming back after stable dx

Question 20

How is time typically billed?

Answer 20

minimum of 30 min pay (even if you see patient for 3 min)

Question 21

time counseling

Answer 21

MUST be documented

average total visit time
patient and family education as well

Question 22

what two times must be documented

Answer 22

total visit time
amount of visit time that was spent coordinating care